Brain tumors are relatively common with an annual incidence of 9 per 100000 for primary brain tumors and 8.3 per 100000 for metastatic brain tumors.  Infrequently, psychiatric symptoms may be the only manifestation of brain tumors. A study by Keschner in 1938 reported that 78% of 530 patients with brain tumors had psychiatric symptoms. However, 18% of the 530 presented only with these symptoms as the first clinical manifestation of a brain tumor.

A 32 years old Phillipino man presented with a 2 weeks history of progressive confusion and memory impairment. Examination confirmed bilateral papilloedema and jamais vu with fugue state.

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MR images confirmed multiple large deep seated tumors in the region of ‘diencephalon’ with no evidence of hydrocephalus.

Symptoms may be misleading, complicating the clinical picture. Any type of psychiatric symptoms can occur with brain tumors. Unfortunately, the symptoms generally do not have any localizing value.

Psychiatric symptoms can be assigned to seven main categories:

  • Depressive symptoms (left frontal lobe tumors),
  • Apathy (The diagnostic criteria for apathy suggested by Starkstein et al[16] include lack of motivation, diminished goal-directed behavior (lack of effort, or dependency on others to structure activity), diminished goal-directed cognition (lack of interest in learning new things or in new experiences, or lack of concern about one’s personal problems), or diminished emotions (unchanging affect, or lack of emotional responsivity to positive or negative events),
  • Manic symptoms (mania was found more commonly with right frontal tumors presenting with characteristics such as euphoria),
  • Psychosis (psychotic symptoms were found in 22% of patients. In these cases of psychotic symptoms, the tumors were found in cerebral cortical, pituitary, pineal and posterior locations. Among these, pituitary gland was the most common location for psychotic symptoms),
  • Personality changes (Frontal lobe lesions and ventricular cysts may present with personality changes. This may include disinhibition, hypersexuality, and aggressive behaviors),
  • Eating disorders (anorexic symptoms may be a result of tumors in numerous locations in the brain, hypothalamic neoplasms most commonly present as anorexia symptoms), and
  • Miscellaneous category for the less frequently encountered symptoms like this patient presenting with jamais vu and fugue state

Neuroimaging is the primary diagnostic modality used to visualize the presence of brain tumors. CT and MRI are used for anatomical assessments. Magnetic resonance spectroscopy is used for the relative quantification of metabolites in different brain locations. Studies of neuronal activity related to local cerebral blood flow is done by functional MRI (fMRI). Positron emission tomography and single-photon emission computed tomography provide images by use of radionuclides.

 

Early diagnosis is critical for improved quality of life. Madhusoodanan (2007) recommended that neuroimaging be considered in the following conditions: new onset psychosis, new-onset mood/memory symptoms, occurrence of new or atypical symptoms, new-onset personality changes, and anorexia without body dysmorphic symptoms. Conditions wherein neuroimaging may or may not be required include recurrence of previously controlled psychiatric symptoms and patients that are refractory to treatment.

This case was essentially ‘inoperable’ but removal of the tumor may completely resolve the psychiatric or behavioral symptoms. Otherwise, decreasing the size of the tumor or halting its growth may also decrease these symptoms. Pharmacological and psychotherapeutic measures can be instituted to improve the functioning and quality of life.